How to qualify for home health services

Aurora Health at Home follows the lead of the Centers for Medicare and Medicaid Services (CMS) when determining whether someone qualifies for home health services. Following CMS guidelines makes it more likely that government insurance, and most private insurance plans, will cover the services we provide.

Before referring someone to Aurora Health at Home, it’s important to understand the criteria for home health services. Only a medical doctor (MD) or doctor of osteopathy (DO) can order home health. NPPs (non-physician providers) can initiate home health services with the confirmation of a verbal order from a MD or DO.

Learn more about Medicare’s home health benefit

Bringing medical services to people’s homes

For home health services, the following criteria must be met:

• Be homebound: Someone who is considered homebound has a normal inability to leave home and is possibly confined for medical reasons. For such people, leaving home takes a considerable or taxing effort and may require assistance.
• Need intermittent (or part-time) skilled services: Skilled nursing, physical therapy, speech therapy and continued occupational therapy all qualify as skilled services.
• Be under the care of a physician: Each referral to home health services must indicate a following physician.
• Have a home health plan of care (POC): Once the plan is in place, the following physician must periodically review it.
• Have a face-to-face encounter: This documented meeting must relate to the primary reason for home health services. It needs to take place no more than 90 days before or 30 days after the start of home health services.
• Have a primary causal diagnosis: This must be associated with the reason for home health services.

What qualifies as skilled nursing?

Skilled nursing services are health-related tasks only performed safely and effectively by a registered nurse (RN) or under the supervision of an RN. These tasks might include:

• Managing chronic disease
• Managing medications
• Giving IV drugs, injections or tube feedings
• Providing education related to these tasks

How is homebound different than bedbound?

While a bedbound or bedridden person must remain in bed, homebound status doesn’t require confinement to the home. A homebound person may occasionally leave home for short periods of time. However, leaving home requires a taxing effort or assistance from medical equipment or another person.

Who can conduct a face-to-face encounter for home health services?

The following health care professionals can perform the required face-to-face meeting:

• Certifying physician
• Acute/post-acute care physician, if someone is directly admitted to home health services from acute or post-acute care
• NPPs (non-physician providers) including nurse practitioners, clinical nurse specialists, nurse-midwives and physician assistants who are under the supervision of the referring physician

Are there any Aurora Health at Home services that do not require the CMS criteria for home health services?

Aurora Health at Home’s services include IV infusion, home medical equipment and hospice care. People are not required by CMS to meet the home health services criteria to receive these services.

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